ROOT COVERAGE PROCEDURES

RIPUNJAY KR TRIPATHI
POST GRADUTE STUDENT

DEPT OF PERIODONTOLOGY
 Contents
• Definition
• Classifications of gingival recession
• Treatment of gingival recession
Nonsurgical
Surgical
• Conclusion
• Références
 Definition
GINGIVAL RECESSION-

Gingival recession is defined as the

apical migration of the junctional epithelium
with exposure of root surfaces. [Kassab MM, Cohen RE-2003].
Gingival recession is the apical shift
of the marginal gingiva from
its normal position on the
crown of the tooth to levels on the root surface beyond the
cemento enamel junction [Loe H-1992].
 Free Gingival Graft (FGG) - A soft tissue graft that is completely detached
from one site and transferred to a remote site. No connection with the
donor site is maintained
Sub-epithelial Connective Tissue Graft (CTG) - A detached connective tissue
graft that is placed beneath a partial thickness flap. This variation of the free
gingival graft provides the tissue graft with a nutrient supply on two surfaces
Classifications Of Gingival Recession
Sullivan and Atkins
 Root Coverage Procedures
Indications:
 root sensitivity
 esthetics
 protect root surface from caries/abrasions
 improved hygiene
Treatment Of Gingival Recession
NON-SURGICAL
 Non –surgical Treatment
Monitoring and prevention

Use of de-sensitizing agents, varnishes

Composite restoration

Removable gingival veneers

Orthodontics
 Monitoring and prevention

If the recession is not progressing and does not provoke tooth

sensitivity or poor aesthetics, then tooth- brushing instructions
and regular observation through a strict maintenance program
would be the optimal treatment.
 De-sensitizing agents, varnishes

Treatment of dentine hypersensitivity is based on blocking the dentinal

tubules and preventing nerve stimulation .
 Composite restorations

Use of composite resin to mask recession defects and eliminate black

triangles caused by recession.
Removable Gingival Veneers
 Orthodontics

In some cases surgical intervention and grafting may help to treat the
recession defect; however, if orthodontic treatment is an option that the
patient is willing to consider then any surgical intervention should be delayed
until after orthodontic tooth movement has been completed.
Indications For Surgical Intervention

The need to improve soft tissue aesthetics

Reduce hypersensitivity

Improve plaque control

Prevent further progression of recession defect

Key factors in the selection of surgical
procedures
RECIPIENT SITE

 Gingival recession is limited to one tooth or extends to multiple teeth

 Degree of gingival recession

 Amount and thickness of existing keratinized gingiva in the area of

recession
 Whether the area of recession protrudes labially from the dental arch

 Restorative/Prosthodontic treatment after root coverage is necessary

Donor site

 Whether area adjacent to gingival recession can be used as a donor site.

 Amount of Keratinized gingiva

 Thickness of keratinized gingiva

 Size of adjacent interdental papilla

 Thickness of the alveolar bone covering the donor tissue

 Thickness of palatal soft tissue used as donor tissue

 Depending on the width of the attached gingiva

if adequate width is present at

If the donor site is associated
the donor site the following
with inadequate width:
procedures can be selected:

a. Laterally (horizontally) displaced flap. Free soft tissue auto graft

b. Double-papilla flap. Sub epithelial connective tissue grafts
c. Coronally-positioned flap are available
 Root Coverage Procedures

Pedicle soft tissue graft procedures :

Rotational flaps

 Laterally positioned flap

 Double papilla flap

Advanced flaps

 Coronally positioned flap

 Semilunar flap
Free soft tissue grafts

Non-submerged graft

 One stage (free gingival graft)

 Two stage (free gingival graft + coronally positioned flap)

Submerged grafts

 Connective tissue graft + laterally positioned flap

 Connective tissue graft + double papilla flap

 Connective tissue graft + coronally positioned flap

 subepithelial connective tissue graft

 Envelope techniques
Additive treatments
•Root surface modification agents

• Enamel matrix proteins

•Guided tissue regeneration

•Non-resorbable membrane barriers

•Resorbable membrane barriers

Laterally Positioned flap

Advantages

a. One surgical site

b. Good vascularity of the pedicle flap.
c. Ability to cover isolated, denuded roots that have adequate donor tissue
laterally.
Disadvantages

a. Limited by the amount of adjacent keratinized attached gingiva.

b. Possibility of recession at the donor site.

c. Dehiscence or fenestration at the donor site.
d. Limited to one or two teeth with gingival recession.
Indications:
a. For covering the isolated denuded root.
b. When there is sufficient width of interdental papilla in the adjacent teeth,
and Sufficient vestibular depth.

Contraindications:
a. Presence of deep interproximal pockets.
b. Excessive root prominence.
c. Deep or extensive root abrasion or erosion.
Procedure for laterally Positioned flap:

 Step I : Preparation of the recipient site

Step 2: Prepare the flap of the donor site.
Step 3: Transfer the flap.
Step 4: Protect the flap and donor site.
 VARIANTS
Satffileno, 1964

partial thickness flap to avoid

recession at donor site

Grupe,1966
Submarginal incision
Sub-marginal pedicle flap
Oblique rotated pedicle flap
 Double papilla flap

Indications:
1. When the interproximal papillae adjacent to the mucogingival problem are
sufficiently wide.
2. When the attached gingiva on an approximating tooth is insufficient to
allow for a Lateral Pedicle Flap.

Advantages:
1. The risk of loss of alveolar bone is minimized because the interdental bone
is more resistant to loss than is radicular bone.
2. The papillae usually supply a greater width of attached gingiva than from
the radicular surface of a tooth.
 Coronally positioned flap

Indications:

• Esthetic coverage of exposed roots.

• For tooth sensitivity owing to gingival recession.

Advantages:

• Treatment of multiple areas of root exposure.

• No need for involvement of adjacent teeth.
• High degree of success.
• Even if the procedure does not work, it does not increase the existing
problem.
Coronally positioned flap

First technique:

Step 1: With 2 vertical incisions.

Step 2: Root preparation
Step 3: Return the flap and suture it coronal to the pretreatment position.
Step 4: Cover the area with a periodontal dressing.
Second Technique (Semilunar flap)
Indication:

 Small localized area

Advantages:

• No vestibular shortening, as occurs with the coronally positioned flap.

• No esthetic compromise of interproximal papillae.

• No need for sutures.
Disadvantages:

• Inability to treat large areas of gingival recession.

• The need for a free gingival graft if there is an underlying dehiscence or
fenestration.
Step 1: Semilunar incision is made and ending about 2 to 3 mm short of the
tip of the papillae.
 Step 2: Perform a split-thickness dissection coronally from the incision, and
connect it to an intrasulcular incision.
 Step 3: The tissue will collapse coronally, covering the denuded root. then
held in its new position for a few minutes with a moist gauze. Many cases
do not require either sutures or periodontal dressing.
Double Lateral sliding bridge flap

Multiple gingival recession with or without adequate attached gingiva

Coronally
Vestibular
advanced plastic surgery
flap
 Reasons for pedicle flap failure

Tension Narrow
Flap

Bone exposed poor

stabilization
 Free Gingival Autograft

that consist of epithelium and a thin layer of underlying CT completely

detached from one site and transferred to a remote site.

Advantages

 Increase keratinized tissue around teeth, implants or crowns and under

removable prostheses.

 Increase vestibular depth.

 Surgi cal Technique

Step 1: Prepare the recipient site.

Step 2: Root preparation:

Root planing of exposed root to remove cementum and affected dentin.

Etch root surface with tetracycline (pH 2.0).

 Step 3: Obtain the graft from the donor site:

The ideal thickness of a graft is 1.0 - 1.5 mm.

Step 4: Graft transferred to recipient site.

Step 5: Protect the donor site.

Sub-epithelial Connective Tissue Graft

Indications:

• Where esthetics is of prime concern

• For covering multiple denuded roots
• In the absence of sufficient width of attached gingiva in the adjacent areas.

Advantages:

• High degree of cosmetic enhancement

• Incurs no additional cost for autogenous donor tissue
• Minimal palatal trauma
• Increased graft vascularity.
Disadvantages:

• High degree of technical skills required.

• Complicated suturing
I. Preparation of recipient site:

 The initial horizontal right angle incision is made into the adjacent
interdental papillae at, or slightly coronal to the cementoenamel junction of
the tooth with an exposed root surface. preserve the papillary blood
supply A partial thickness flap is raised without vertical incisions
SRP Root Conditioning with citric acid pH 1.0 or tetracycline HCl in a
concentration of 250 mg mixed in 5 ml of sterile water  approximate
mesio distal width necessary for the graft is measured with a periodontal
probe.
II. Excision of the donor tissue

1st incision  horizontal incision 2-3mm apical to gingival margin

2nd incision  parallel to the long axis of the teeth, 1 to 2 mm apical to the
first incision raise a full thickness periosteal connective tissue graft
III. Grafting to the recipient site:

 With interrupted sutures

Pouch and Tunnel technique

Create “pouch” using full thickness incision and maintain papilla for
bilaminar blood supply.
 Extend incision to adjacent teeth and undermine flap beyond MGJ, which
allows the coronal positioning of the flap.
 Insertion of CTG and suture.
Guided Tissue Regeneration
Indications

• Esthetic demand.
• Indicated for single tooth with wide, deep localized recessions.
• For areas of root sensitivity where oral hygiene is impaired.
• For repair of recessions associated with failing or unesthetic class V
restorations.
Advantages:

• Techniques does not require a secondary donor surgical site reducing

postoperative discomfort.
• New tissue blends evenly with the adjacent tissue, providing highly esthetic
results.

Disadvantages:

• It is sensitive technique.
• Insurance of additional cost of barrier membrane.
Step 1: A full-thickness flap is reflected to MGJ, continuing as a partial-
thickness flap 8 mm apical to MGJ.
Step 2: Root preparation.
 Step 3: A membrane is placed over the root surface and the adjacent tissue
at least 2 mm of marginal periosteum.

 Step 4: The flap is then positioned coronally and sutured.

The use of Allografts and Xenografts in
management
systematic review concluded that these grafts may be useful in situations
where

1- A large recession defect needs to be treated .

2- Graft tissue harvested from the palate would provide an insufficient
volume of tissue.
Modifications

a. Titanium–reinforced membranes  used to create the space below the

membrane.

b. Resorbable membranes have been used to prevent a second surgery

Criteria of successful root coverage

The gingival margin is on the CEJ in class I, Class II.

The depth of gingival sulcus is within 2mm.

There is no bleeding on probing , hypersensitivity.

Color match with adjacent tissue

 Conclusion
 The management of gingival recession and its sequelae is based on a thorough
assessment of the etiological factors and the degree of involvement of the
tissues. The initial part of the management of the patient with gingival recession
should be preventive and any pain should be managed and disease should be
treated.

 The degree of gingival recession should be monitored for signs of further

progression. When esthetics is the priority and periodontal health is good then
surgical root coverage is a potentially useful therapy.

 Numerous therapeutic solutions for recession defects have been proposed in

the periodontal literature and modified with time according to the evolution of
clinical knowledge.
 The subepithelial connective tissue graft with a cornonally advanced flap is
gold standard grafting procedure .

 Prognosis (amount of root coverage achieved) will depend on the severity

(size )of recession .

 Careful case selection and surgical management are critical if a successful

outcome is to be achieved.
 References

 Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima

LA. Root coverage procedures for the treatment of localised recession-type
defects (Review). The Cochrane Library 2009, Issue 2

 Umberto Pagliaro, Michele Nieri, Debora Franceschi,Carlo Clauser,and

Giovanpaolo Pini-Prato. Evidence-Based Mucogingival Therapy. Part 1: A
Critical Review of the Literature on Root Coverage Procedures. J Periodontol
May 2003

 Paulom. Camargo, Philip R.Melnick & E. Barrie Kenney.The use of free

gingival grafts for aesthetic purposes . Periodontology 2000, Vol. 27, 2001,
 Philippe bouchard, Jacquesmalet & Alain borghetti. Decision-making in
aesthetics: root coverage revisited - - Periodontology 2000, Vol. 27, 2001

 Kassab MM, Badawi H, Dentino AR. Treatment of gingival recession. Dent

Clin North Am. 2010;54:129-140.

M. Zalkind.Alternative method of conservative esthetic treatment for gingival

recession J Prosthet dent 1997 77 561-563
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